Completed plans to become an ECRI affiliate and join forces to share lifesaving information and further a vision of safe, high-quality healthcare.
Announced plans for affiliation with ECRI Institute to create one of the largest healthcare quality and safety entities in the world.
Published recommendations to prevent errors with neuromuscular blockers and championed healthcare practitioners by calling for system-based response, not criminal prosecution of an individual, following medication error.
Issued new guidelines for safe electronic communications of medication information and updated guidelines for the safe use of automated dispensing cabinets.
Created the Medication Safety Board (MSB) to assist the healthcare industry with package and label design, risk assessment, and other safety consulting services.
Celebrated ISMP's 25th anniversary of official incorporation and helping make a difference in the lives of millions of patients and healthcare professionals.
Held the 22nd Annual ISMP Cheers Awards dinner to honor medication safety leaders and innovators.
ISMP launches the 2018-19 Targeted Medication Safety Best Practices for Hospitals, the purpose of which is is to identify, inspire, and mobilize widespread, national adoption of consensus-based best practices for specific medication safety issues that continue to cause fatal and harmful errors in patients, despite repeated warnings in ISMP publications.
Launch of ISMP's Gap Analysis Tool (GAT) for Safe IV Push Medication Practices, designed to heighten healthcare practitioners’ awareness of safe medication systems and practices associated with IV push medication use in adult patients, assist healthcare practitioners with identifying and prioritizing opportunities for reducing patient harm and create a baseline of national efforts to enhance safety when preparing, dispensing, and administering, IV push medications in adults.
ISMP President Michael R. Cohen receives ASHP's Zellmer Lecture Award.
Release of white paper entitled Call to Action: The Case for Medication Safety Officers (MSO) stressing the need for MSOs to be included as an integral part of the healthcare team and providing detailed information for hospital leadership on the value of creating a dedicated position directly responsible for and empowered to lead medication safety strategy and implementation.
Launch of High-Alert Medication Safety Self Assessment, which helps hospitals and certain outpatient settings evaluate their best practices related to specific high-alert medications, identify opportunities for improvement, and track their experiences over time.
Worked with Global Enteral Device Supplier Association (GEDSA) to alert health systems to safety issues surrounding upcoming introduction of new ENFit enteral feeding tube connectors.
ISMP holds the first National Summit on Safe Practices Associated with IV Push Medication Administration for Adults, funded by BD, to develop a set of best practices that will facilitate safe administration.
Published an analysis and comparison of results from the 2000 and 2011 ISMP Medication Safety Self Assessments in The Joint Commission Journal on Quality and Patient Safety that helped better define the current state of medication safety.
Issued National Alert Network (NAN)alert on confusion regarding the generic name of the HER2-targeted drug KADCYLA (ado-trastuzumab emtansine), spurring FDA to send out its own alert around three weeks later.
Another National Alert Network (NAN) alert is issued on severe burns and permanent scarring after glacial acetic acid (≥ 99.5%) is mistakenly applied topically and has a particularly wide reach—it is distributed internally by Boards of Pharmacy, state hospital associations, and members of the American College of Gastroenterology in addition to alert network members.
As a result of persistent, ongoing safety issues, ISMP calls on hospitals to closely reexamine their policies regarding insulin pen devices, and consider transitioning away from insulin pens for routine inpatient use.
Introduced a new monthly publication, the Long-Term Care Advise-ERR™, which is the first publication dedicated to giving administrators, and all healthcare personnel (physicians, nurses, consultant pharmacists) caring with elderly residents lifesaving information on preventing medication errors.
Announced that The American Society of Medication Safety Officers (ASMSO) will become part of the Institute under the new name Medication Safety Officers Society (MSOS) to provide a framework for meeting the needs of the Medication Safety Officer community on an international scale.
Released a statement and advocated for practices to help safeguard patients from errors after a national outbreak of a rare form of fungal meningitis, caused by contaminated steroid shots prepared by a compounding pharmacy in Massachusetts.
Launched its third national patient safety reporting program to capture the unique causes and consequences of vaccine-related errors. The ISMP National Vaccine Error Reporting Program (ISMP VERP) allows healthcare practitioners from all practice settings to report errors and near misses in confidence.
ISMP shared the results of its survey gathering practitioner feedback on implementation of drug storage, stability, and beyond use dating requirements with the Centers for Medicare & Medicaid (CMS) and Joint Commission.
ISMP conducted survey linking community pharmacy “guarantees” to fill prescriptions within a specified time to medication errors and continues to advocate for change on a national level.
ISMP’s survey highlighted differences in nursing, pharmacy, and risk/quality/safety manager perspectives on what constitutes a high-alert drug (one more likely to cause significant patient harm when used in error). Information gathered is used to update ISMP’s List of High-Alert Medications in the Acute Care setting.
ISMP releases Guidelines for Timely Medication Administration, a guidance document respondng to the controversial CMS “30 minute rule” for medication administration in acute care to help healthcare organizations with the timely administration of medications. ISMP’s survey, guidance, and continued advocacy on this issue results in changes in the rule.
The 2011 ISMP Medication Safety Self Assessment® is launched to document the progress of U.S. hospitals in medication safety and identify the impact of new challenges that have arisen since 2004, such as drug and staffing shortages, shrinking reimbursement systems, and the application of new technology.
ISMP releases results of survey on drug shortage “Gray Market,” which continues to increase national dialogue on the issue, including the launch of an investigation by Rep. Elijah Cummings (D-Md) into several companies suspected of buying and selling on the gray market.
A National Alert Network (NAN) message is issued by ASHP and ISMP, warning practitioners that potentially fatal errors may occur with dosing for the antibiotic colstimethate for injection.
More than 17,500 nurses tell ISMP that the CMS “30 minute rule” for scheduled medications can lead to patient harm. ISMP begins drafting a guidance document to help practitioners implement the rule.
An ISMP survey showed that the U.S. economic downturn may have compromised medication safety, taking a toll on hospitals and forcing them to take steps that put patients at greater risk. The survey gained widespread news coverage.
ISMP issues Guidelines for Standard Order Sets to ensure that computerized prescriber order entry (CPOE) order sets are carefully designed, reviewed and maintained to prevent potential errors.
ISMP publishes a case study of a well-publicized error that resulted in the death of a 16-year old patient the Joint Commission Journal on Quality and Patient Safety. The article serves as a teaching tool that supports a system-based approach to safety.
A National Alert Network (NAN) message is issued by ASHP and ISMP, warning healthcare practitioners about dangerous medication errors that could be caused by a shortage of EPINEPHrine pre-filled syringes.
Began to use social media technology for medication safety advocacy, through the creation of a new weekly blog for the Philadelphia Inquirer, as well as through Facebook and Twitter.
The FDA alerts healthcare providers to insulin safety issues as a direct result of ISMP notifications and newsletter coverage. A safety alert and drug safety newsletter coverage from the agency pass on ISMP’s warnings regarding sharing insulin pens between patients and removing insulin from cartons.
Following numerous reports of potential safety problems in the hospital management of elastomeric pain relief pumps, ISMP called on healthcare organizations to review their processes and procedures for utilizing these devices to provide surgical wound analgesia and/or peripheral nerve block.
ISMP warned healthcare practitioners that IV solutions administered post-operatively can cause low sodium levels and death in healthy children. The Institute called for more education on the causes, signs, and symptoms of this condition.
ISMP opposes criminal charges for a former Ohio pharmacist involved in a 2006 fatal medication error. The Institute also helps him educate other healthcare professionals about what can be learned from his case.
ISMP, HRET, and MGMA release Pathways for Patient Safety™, a series of web-based tools aimed at increasing awareness, knowledge, and implementation of best practices to reduce the risk of patient harm in physician practices.
ISMP holds the first two-day ISMP Medication Safety Intensive Workshop to help practitioners establish aggressive, focused medication safety program and the infrastructure necessary for continued safety improvements.
ISMP becomes one of the first federally certified Patient Safety Organizations (PSOs), providing healthcare practitioners and organizations with the highest level of legal protection and confidentiality for patient safety data and error reports they submit to the Institute.
The release of ISMP’s first QuarterWatch™ report identifies possible safety concerns with the smoking cessation drug Varenicline (Chantix) and offers recommendations for safe use. The report generates huge national media attention, and causes the Federal Aviation Administration (FAA), U.S. Federal Motor Carrier Safety Administration, and Department of Defense to essentially ban or warn against its use.
ISMP helps form the National Alert Network (NAN) along withthe National Coordinating Council on Medication Error Reporting and Prevention (NCCMERP) and the American Society of Health-System Pharmacists (ASHP). The coalition begins to distribute alerts about medication errors that have caused or may cause serious harm or death—the information comes from ISMP’s voluntary reporting program.
ISMP holds a national summit on smart pumps that brings together vendors and users to identify best practices and ways to prevent errors at point-of-care.
ISMP President Michael R. Cohen receives a 2008 John M. Eisenberg Patient Safety and Quality Award for his life-long professional commitment to promoting safe medication use and safe medication delivery systems.
ISMP moves into new office at 200 Lakeside Drive, Suite 200, in Horsham, PA
Archives of Internal Medicine publishes report co-authored by ISMP that shows adverse drug events reported to FDA more than doubled between 1998 and 2005, as did the deaths associated with adverse drug events. Report is widely covered in the media.
With continued reports of fentaNYL transdermal patches being prescribed inappropriately to treat post-operative pain in opioid-naïve patients, ISMP again issues national warning about patch misuse that restates error prevention recommendations.
ISMP opposes criminal charges for Wisconsin nurse involved in a fatal medication error, supporting the Wisconsin Hospital Association and Wisconsin Nurses Association stance that criminal prosecution of a healthcare professional for an unintentional error is inappropriate and unwarranted.
As a result of the ISMP-FDA abbreviations campaign, the list of dangerous abbreviations is included in the style guide for the Journal of the American Medical Association (JAMA) and Physicians’ Desk Reference (PDR).
ISMP advocates changes in Tylenol blister package design with FDA and McNeil Consumer & Specialty Pharmaceuticals to reduce risk of improper dosing. McNeil recalls several Tylenol products for children as a direct result of ISMP’s alert. Due in part to ISMP’s advocacy, JCAHO announces new 2006 Patient Safety Goal requiring labeling of all medications, medication containers, or other solutions on and off the sterile field in operative and other medical procedure settings.
ISMP and the FDA partner on a comprehensive educational campaign to eliminate potentially harmful abbreviations and a joint public meeting on labeling of large volume parenterals. In addition, ISMP presents at a public hearing on the FDA Center for Drug Evaluation and Research’s current risk management strategies for human drugs.
Michael R. Cohen, RPh, MS, ScD (hon), ISMP President, is honored with a prestigious 2005 John D. and Catherine T. MacArthur Foundation Fellowship.
ISMP celebrates 10th anniversary of its incorporation as a nonprofit organization, and nearly 30 years of experience in improving the safety of medical products and professional practice.
ISMP issues a white paper on the effect of bar coding unit doses on reducing medication errors.
ISMP, AHA, and HRET release Pathways for Medication Safety; includes three tools to help hospitals with strategic planning, risk assessment, and bar code readiness.
Lifetime Achievement Award, presented during ISMP's Cheers Awards Dinner, is created to honor the memory of ISMP Trustee David Vogel. The award recognizes individuals who have had a major impact on safe medication practices.
The FDA agrees to require tall man lettering for twenty name pairs after an ISMP request.
ISMP staff testify before House Committee on Ways and Means subcommittee hearing on quality issues related to the design of prescription drug benefit program for Medicare beneficiaries.
ISMP's international affiliate organization, ISMP-Canada, is established.
First ISMP Medication Safety Self Assessment for Hospitals® is conducted—more than 1,400 hospitals respond, establishing a baseline for future change. Survey helps hospitals evaluate their medication use practices and compare them to demographically similar U.S. hospitals.
ISMP publishes warning and flies petition with United States Adopted Names Council (USAN) that leads to renaming of amrinone as inamrinone, to prevent cases of fatal sound-alike confusion with amiodarone.
ISMP receives AHA Award of Honor for dedication to the safe and improved use of medications.
ISMP publishes a white paper on electronic prescribing, calling for the elimination of handwritten prescriptions.
ISMP's international affiliate organization, ISMP-Spain, is established.
ISMP partners with the American Hospital Association (AHA) in national initiative to help hospitals examine and further improve medication safety. ISMP staff meet with President Clinton and participate in White House press briefing to announce the project.
ISMP participates in national policy discussions exploring types of error reporting programs, including testifying in House and Senate hearings and participating in a Senate staff briefing.
First edition of book, Medication Errors, by ISMP President and Founder Michael R. Cohen, is published by the American Pharmaceutical Association
The Cheers Awards dinner, which honors individuals and organizations that have set a standard of excellence in the prevention of medication errors and adverse events, is established.
ISMP begins formal campaign that spurs the Veterans Administration to require removal, and the Joint Commission (TJC) to urge nationwide removal, of potassium chloride for injection concentrate from all patient care areas.
Institute becomes founding member of the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP); influences decision to require greater specificity and clarity in prescription writing, such as eliminating doses with decimal points.
ISMP convenes a national meeting to discuss elimination of cardiac lidocaine in 1 and 2 g concentrate prefilled syringes, due to reports of deaths from mix-ups with 100 mg prefilled syringes. As a result of ISMP's advocacy, these products are subsequently removed from the market by their manufacturers.
ISMP President Michael R. Cohenappears on the premier segment of the program Dateline NBC, to discuss fatal medication errors, including a vincristine overdose that killed a small child.
First scholarly publication in the medical literature about the dangers of free-flow infusion pumps appears with ISMP-authored article in Hospital Pharmacy.
National, confidential, voluntary medication error reporting program (MERP) is created by ISMP in coordination with the United States Pharmacopeia (USP) to provide expert analysis of the system causes of medication errors.
ISMP promotes changing vincristine labeling to reduce the likelihood of inadvertent intrathecal injection; this advocacy leads to an updated USP standard.
ISMP convenes national meeting that influences the United States Pharmacopeia (USP) and U.S. Food and Drug Administration (FDA) to require that potassium chloride concentrate for injection have black caps, closures, and warning statements to prevent mix-ups with other parenteral drugs.
First ISMP list of dangerous medical abbreviations published in Nursing ’87 magazine.
First printing of Medication Errors: Causes and Prevention, a comprehensive book on the causes and prevention of drug mistakes, written by Michael Cohen and Neil Davis, ISMP cofounders.
ISMP’s work officially begins with a continuing column on medication safety in Hospital Pharmacy (now published by Thomas Land Publishers).